Health Care Reform:

Health Insurance & Affordable Care Act

Is it OK for your doctor to fudge health information in order to help you get your treatment covered by your health insurance plan? The practice certainly seems widespread, new findings indicate.

http://img.webmd.com/dtmcms/live/webmdNone

Doctors Willing to Deceive Health Plans for Patients

continued...

The announcement, which is a step toward giving doctors more control over the decisions they make regarding your care, could also be a step toward reducing the widespread gaming that was reported in the JAMA survey.

In that national survey, 720 doctors were asked whether in the last year they had "sometimes" -- or more frequently -- exaggerated a patient's condition, changed a billing diagnosis, or reported symptoms that were not present. Some 39% of the respondents reported that they had done so to gain payment for services that they believed were necessary.

Suggesting a possible link with increasingly aggressive managed care cost-control practices, more than half of these physicians said they gamed the system more frequently than they had five years earlier. Yet 61% of physicians said that they rarely or never manipulated payment rules.

Additional survey questions revealed that doctors' willingness to manipulate health plan rules was strongly linked to their belief that such behavior was necessary to provide high-quality care. Almost 29% of the survey's physicians thought it necessary to game the system to provide high-quality care. Nevertheless, just over 15% of the physicians in the survey said that they believed it was ethical to do so.

"They are being asked to do something that they believe is unethical in order to do a good job," Wynia tells WebMD.

But Young disagrees, saying "there is no question in the research literature that 20% or more of health care services are unnecessary. Doctors are doing whatever they can to lash out against managed care."

Of the doctors surveyed, 37% reported that patients had requested that they deceive their health plan, a factor that Wynia says correlated strongly with physicians who reported that they gamed the system. And doctors who said that they had insufficient time with their patients also were more likely to engage in deceptive practices.

Young notes that this deception by doctors brings "potential harm" to patients. "If you put something on a medical record, a diagnosis that is not accurate, the individual then could have that diagnosis carried with them," he tells WebMD. "If you put down diabetes when in fact they don't have diabetes ? it may interfere with their getting life insurance."